Study: High rate of PTSD among female Vietnam War vets

The Vietnam Women's Memorial in Washington, D.C. Women who served in Vietnam suffer significant rates of post-traumatic stress disorder decades after the war, partly because of the pervasive sexual harassment and discrimination they faced, according to a new JAMA study.

Female Vietnam War veterans suffer significant rates of post-traumatic stress disorder decades after the war, partly because of the sexual harassment and discrimination they faced while attending to the wounded and dying, according to a new study.

Of the women surveyed, 20 percent experienced PTSD at some point after the war, according to the study published this week in JAMA Psychiatry, a publication of the Journal of the American Medical Association. Most of these women were nurses. Nearly 16 percent currently suffered from the disorder at the time of the study.

By contrast, among military women of the era who remained in the United States, 14 percent had experienced PTSD, with 9 percent still suffering from it. Women who served near Vietnam — for example, in Thailand or the Philippines — had the lowest rates of the disorder: 11.5 percent experienced PTSD and 8 percent currently had the disorder.

The study, funded by the Department of Veterans Affairs, is based on surveys and phone interviews of more than 4,000 Vietnam-era female veterans. Of these, 1,956 had been stationed in Vietnam, mostly in the Army; 657 had served nearby on bases in Asia, mostly in the Air Force; and 1,606 had served in the U.S.

“Vietnam service significantly increased the odds of PTSD relative to U.S. service; this effect appears to be related to wartime exposures, especially sexual discrimination or harassment and job performance pressures,” the study concludes.

The Health of Vietnam-Era Women’s Study spotlights what has been a little-examined part of the nation’s experience in Vietnam.

“I truly hope that this study will help the women who served so admirably during the Vietnam era, as they have been overlooked for a long time,” co-author Kathryn Magruder, who is affiliated with the Ralph H. Johnson Veterans Affairs Medical Center in Charleston, S.C., said in an email. “It’s never too late to do the right thing.”

Some 6,000 women served in Vietnam, all of them voluntarily, most of them nurses, many of them young and inexperienced.

“They were young, and though they had nursing degrees, most were just out of school. Hard to imagine that they could be prepared for what they would face in Vietnam,” Magruder said.

The study represents the largest sample collected of female veterans who served during the Vietnam era, and it is thought to be unique in its comparisons among locations where the veterans served. Unlike most studies of female veterans, based on women who use VA health care services, this one was population-based.

The study found a far higher rate of current, war-zone related PTSD in female Vietnam veterans than another PTSD study published in July. The National Vietnam Veterans Longitudinal Study found similar rates of lifetime prevalence of PTSD. But the NVVLS found that more than half of the women recovered — with less than 9 percent of female Vietnam veterans currently suffering.

The difference may be explained by how the studies were conducted, experts said. The NVVLS used the most current diagnostic criteria, considered more conservative than the previous diagnostic criteria, which was used in the newest study.

Dr. Charles Marmar, chairman of the psychiatry department at New York University Langone Medical Center and director of the NYU Cohen Veterans Center, a co-author of the NVVLS study, said because there are no biological tests for PTSD, correctly diagnosing it remains problematic. “Who knows whether the (older or most current diagnostic system) is the better system?” he said.

In addition, the new study used lay interviewers in its thousands of computer-assisted interviews, while the NVVLS used expert clinicians to conduct interviews with about 600 women, a far smaller but statistically representative sample of female veterans, according to authors of the earlier study.

Expert clinicians are more likely to help interviewees understand and correctly report the difference between, for instance, a flashback and an intense memory. A flashback or re-experiencing of trauma would be a symptom of PTSD; a memory of it, although unpleasant, would not be.

A limitation of the most recent study, according to its authors, was that more than half of the original study group identified did not participate fully, if at all. Many of the women had died, researchers said, but they acknowledged that those still living who didn’t respond might have had a different experience. Still, they noted, they had by far the largest number of women studied.

Another difference: The newer study defined “current” PTSD as having occurred in the last year. The NVVLS defined “current” as in the past month.

The study did not delineate sexual harassment, a broad term that can encompass unwanted propositions and other sexual bullying to being stalked to the life-threatening, physical trauma of rape, the sort of trauma long associated with increased risk of PTSD.

“Sexual discrimination or harassment, which is not thought of as a unique war zone exposure, was higher among deployed women and significantly related to PTSD in every model,” according to the study.

Likewise, job pressure and sexual discrimination are not generally considered “trauma,” Magruder said.

But nurses deployed to Vietnam often worked 12-hour shifts, six days a week, and were responsible for triage decisions, deciding sometimes who would live and who would not, according to historians. At the same time, in an overwhelmingly male-dominated combat theater, an era in which women were considered inferior to men in most regards, they were suspect.

“Each WAF (woman in the Air Force) in SEA (Southeast Asia) realized that she was on trial,” according to an online history written by two retired female Air Force general officers who served during Vietnam. “In addition to adapting to the combat theater environment, she was conscious of living in a fishbowl where her professional competence, her personal character and her courage were always subject to critical scrutiny.

“Even those who were not nurses had difficulties — so it wasn’t just the carnage that the nurses experienced,” Magruder said.

Still, Marmar said, four decades of clinical experience with Vietnam nurses showed that those who’d suffered PTSD had overwhelmingly cited the same traumas.

“There’s no question from our experience, the biggest stressors were sexual harassment and assault, and triage and death,” Marmar said. “Exposure to death and dying, sexual harassment and assault, gruesome injuries, guilt over triage.

“Young people dying in your arms and you have to make a Sophie’s choice: This one’s too far gone. Having people dying under your care is very disturbing.”